HPI:
14 y/o male soccer player presents to clinic with 12 months of right gluteal pain when active or sitting for a prolonged time. He described the pain as dull with normal activity and sharp with low levels of exertion particularly in hip flexion. His pain is maximal during soccer while kicking the ball with his opposite foot. In addition, he reports point tenderness over the proximal right hamstring and while sitting down on hard surfaces. He was evaluated roughly 1 year ago by an outside physician with a normal XR of the pelvis. Per patient and father reported an “injury to the Sits bone”. Patient was subsequently taken out of sports for 6 months and had a non-US guided corticosteroid injection into the posterior thigh 3 months prior to clinic visit. The injection provided short term relief, no additional treatment (PT) was prescribed.
ROS:
CONSTITUTIONAL: No fevers, chills, sweats, night pain or weight changes.CARDIOVASCULAR: No chest pains, palpitations, orthopnea and paroxysmal nocturnal dyspnea.RESPIRATORY: No dyspnea on exertion, no wheezing or cough.MUSCULOSKELETAL: per HPINEUROLOGIC: No numbness, tingling or weakness.
Physical exam:
Gait: Able to bear weight with a normal gait
MSK: No swelling, ecchymosis
ROM:  Full ROM intact both actively and passively. There was mild pain with active deep flexion during squat
Straight leg raise: Significant for pain on proximal right hamstring
Tenderness: Over ischial tuberosity and toward proximal hamstring
Strength: 4/5 on hip extension remainder of strength testing unremarkable
Log Roll: neg
FABER/FADIR neg/neg
Ober Test: neg
Thomas Test: neg
Sensation: intact to light touch
Differential Diagnosis:
Chronic hamstring strain
Bone contusion
Tumor
Osteomyelitis
Initial Testing In clinic:
X-Ray Hip AP/lateral:
Irregular lucency along inferolateral aspect of right ischium. Correlates to insertion of the hamstring. However, the appearance is not typical for an avulsion injury or tendon strain. Femoro-acetabular joints preserved.
MRI: Ill-defined area within the ischium approximately 1.7 x 0.6 x 3.6 cm corresponding to the suspicious area seen on prior x-ray. Findings are likely due to a healing avulsion fracture of the right ischial tuberosity.
Final Working Diagnosis:
Healing avulsion fracture over right ischial tuberosity, clinically improving with PT